Part I: Inverted Pyramid Use the four (4) step method to assess the client.
Step 1: Problem Identification: Be thorough
Step 2: Thematic Groupings: Don't forget to also add a narrative based on the 4 D's
Descriptive Diagnosis- Show clinical problem by criterion in DSM-5(Symptoms of Client)
Clinical Targets- Formed by thoughts, feelings, behavior and physiology of client.
Function/Dysfunction- Show areas of dysfunction in life situation, relationships, and skills.
Intrapsychic- How the client sees themselves in relation to their environment or others around them.
1. Danger 2. Distress? 3. Deviance? 4. Dysfunction
If none type NA for each
Step 3: Theoretical Inferences: Don't forget to provide citations add justification's for your choice
Theory and Therapy
Step 4: Narrowed Inferences
Sum up what's going on with client.
Part II: Treatment Planning : Use the four (4) step method to develop your treatment plan
Revisit 4D's
Step 1: Behavioral Definitions- Remember you can get these from the inverted pyramid
Step 2: Identify & Articulate SMART Goals:Two LTG & Two STG goals- objectives (each)- using this tip: Don't forget to use SMART Goals and the 3-I's to treatment planning
Identify, Implement and Insight = 3D's
Step 3: Therapeutic Intervention: Don't forget to justify this step with citations and a brief narrative of why this intervention is appropriate
Step 4: Outcome measurements (for each goal) Don't forget to provide a DIAGNOSTIC TOOL (both reliable and valid)